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From Dawn to Hope: A Journey of resilience and progress in HIV Therapy.

Reflections after attending the International AIDS Society 2023 Meeting in Brisbane Australia

In the early hours, before dawn, Mai Tendai stirs from her mat on the floor. The rooster is still in slumber. She tiptoes to the corner of their small rural home, careful not to disturb her five sleeping children. She retrieves the water she had fetched from the river the day before places it into a battered aluminum pot, and upon her stove. The kindling, gathered by her sons from the sparse woods nearby, crackles. Mai Tendai fans the fire, the smell of wood smoke fills the air, it clings to her clothes and nestles in her tightly coiled hair, a smell she has come to resent.

As the water starts to boil, she stirs in the maize flour, watching as the mixture turns into a thick, creamy porridge. There's no milk or sugar today. She makes a mental note to grind some peanuts later and prepare homemade peanut butter so that she can add protein (as the nurses at the clinic had advised) and enhance the taste of her porridge.

As the first cocks crow, her children begin to stir, yawning and stretching out of sleep. She serves them the warm porridge, their young faces, still hazy from sleep, lighting up at the simple meal. She readies them for school, ensuring each has their books and their uniforms are presentable, before she too sets off on her journey.

She commences her 15 km walk to the clinic. She walks briskly, if she arrives too late, she may not get attended to in good time. The clinic is a simple structure but has been life saving for her. No longer does she need to endure the bus trip to the city for her medications. Mai Tendai has been living with HIV for the last 7 years. On arrival she is greeted by the familiar bustle of the clinic - nurses moving hurriedly, patients waiting patiently. Today, she will collect her antiretroviral drug refill, that should last her another three months. She also anticipates the results of her recent viral load test, silently praying for an undetectable status.

Yet, amidst the waiting and anxiety, she is filled with optism that things will only get better. She has witnessed the advancements in HIV treatment. The leaps made over the years ignite her hope for a future where access to treatment is even easier, not only for her but also for her youngest child who also lives with HIV.

Last week, the International AIDS Society hosted a meeting on HIV cure and immunotherapy. HIV, as a retroviral infection, poses significant hurdles to achieving a cure due to its ability to integrate into the host's DNA and hide within what we term as the latent HIV reservoir, thereby evading the immune system. But the scientific community is persistent and determined to answer even the most daunting questions, such as ‘how do you eradicate a retrovirus from an infected host?’. This conference brought together a diverse set of minds, including scientists, doctors, people living with HIV, and activists, to ponder over what needs to be done to achieve a cure or long-acting immunotherapy and what it might signify.

The community acknowledged the importance of language and the weighty implications of the term 'cure'. We acknowledged the challenges ahead and that complete virus eradication for the millions living with HIV today is unlikely in the near term. However, we maintain optimism that it may be possible to achieve immune-based viral control via immunotherapies. Achieving this will not be a simple task, it will require global collaboration and relentless efforts to understand and harness the immune system, and to develop novel therapeutic approaches like vaccines, broadly neutralizing antibodies, appropriate immune modulators and latency reversal agents.

The meeting was an invigorating experience. As we celebrated the impressive impact of antiretrovirals on HIV, we also challenged ourselves to find innovative solutions. The community of people living with HIV reminded us of the importance of their inclusion in research from conception through to implementation. They reminded us of how critical it is to understand their needs and concerns, especially when testing new therapies.

The journey towards making life easier for people like Mai Tendai and infected children is long. Advances such as long-acting antivirals provide hope but have not reached many like her. Our interventions will need to not only be safe and effective but also be easy to administer, and last at least 3 or 6-months if not longer. Much remains to be done, but step by step, progress is being made.

Blog post by Tariro Makadzange an infectious disease physician, viral immunologist and public health researcher working at CRMG and Mutala Trust in Harare.

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